Jefferson Benefits Guidebook 2018 - Human Resources
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2018 Jefferson Benefits Guidebook
IMPORTANT! Benefits Enrollment Information Open Enrollment for the 2018 Plan Year is processed exclusively online from October 16–30, 2017. All employees must go online during Open Enrollment and actively elect benefits even if you want to keep the same level of coverage. The benefits you elect during open enrollment will remain in effect for the entire plan year unless you experience a qualified life event. It's the employee's responsibility to contact HR Operations to report the qualified event. Changes must be made within 30 days of date of the event. New hire elections are processed exclusively online and must be made within 30 days of hire.
TABLE OF CONTENTS
HUMAN RESOURCES 2-4 DENTAL PLANS 25-26
Online 2 Dental Plans at a Glance 25
Access Employee Self-Service 2 Delta Dental of PA 26
Your Campus Key and Password 2 Cost of Coverage 26
HR Business Partner 2
Total Compensation Statement 2 LIFE INSURANCE PLANS 27-28
Eligibility 3 Basic Life and AD&D Insurance 27
Part-Time Employee Benefit Program 3 Supplemental Life and AD&D Insurance 27
Eligible Dependents 4 Cost of Coverage 27
Proof of Dependents’ Status 4 Supplemental Insurance Rates 28
Converting to an Individual Policy 28
HOW AND WHEN TO ENROLL FOR COVERAGE 5-6 Age Reduction 28
Open Enrollment 5 Medical Evidence of Insurability 28
Changing Your Benefits Due to a Life Event 5 Imputed Income 28
Verify Your Elections 5 Long-Term Disability 28
When Coverage Ends 6
BUSINESS TRAVEL ACCIDENT INSURANCE 28
COBRA 6 How the Plan Works 28
COBRA Rates 6 Cost of Coverage 28
LIVEWELL@JEFF 7-8 DISABILITY PLANS 29-31
Short-Term Disability 29
MEDICAL PLANS 9-16
Your Short-Term Disability Choices 29
Medical Plans at a Glance 9 How the Short-Term Disability Plan Works 29
Terms to Know 9 Cost of Coverage 29
Cost of Coverage 10 Pre-Existing Conditions 29
Platinum and Gold PPO Plans 11 Long-Term Disability 30
How the Platinum and Gold Plans Work 11 Your LTD Choices (Except Clinical Faculty) 30
The JeffCare Hospital Network 11 How the Long-Term Disability Plan Works 30
Livongo for Diabetes 12 Cost of Coverage 30
What is Not Covered? 12 Pre-Existing Conditions 30
Platinum PPO Plan Summary 13-14 LTD Benefit Period 31
Gold PPO Plan Summary 15-16 LTD (Clinical Faculty) 31
PRESCRIPTION PLAN 17-21 FLEXIBLE SPENDING ACCOUNTS 32-33
How the Plans Work 17 Flexible Spending Accounts at a Glance 32
MedImpact Home Delivery 17 Discovery Benefits Debit Card 33
Mandatory Generic Drugs 18 Discrimination 33
Prescription Management Programs 18 FSA Store 33
Prescription Benefits at a Glance 19 Additional Information 33
Save on Prescriptions 19
Domestic Pharmacy Locations 19 VOLUNTARY BENEFITS 34
Smoking Cessation 20
Filling Prescription While Away 20 YOUR OTHER BENEFITS 35-37
Charges Not Covered 20 Retirement Plans 35
Out-of-Pocket Maximum 20 Tuition Assistance 36
Selecting the Right Medical/Rx Plan for You 21 Dependent Scholarship 36
Vacation or Earned Time Off 37
VISION PLAN 23-24
Davis Vision Benefits at a Glance 23 BI-WEEKLY EMPLOYEE CONTRIBUTION RATE SHEET 38
Davis Participating Partners 24
BENEFITS SERVICE PROVIDER CONTACT LIST 39
Out-of-Network Benefits 24
Reimbursement Schedule 24 TO COMPLETE THE ENROLLMENT PROCESS 40
Cost of Coverage 24
For additional benefits information please view our website,
hr.jefferson.edu. Click on benefits located in the menu on
the left side of the page.
READY TO ENROLL? Go to page 40 for instructions. TABLE OF CONTENTS 1
Human Resources
ONLINE Access Employee
The Human Resources website, hr.jefferson.edu,
provides you a wealth of benefit information and tools: Self-Service
• Compare medical plans
FROM WORK
• View benefit overviews and plan summaries
Using Internet Explorer 11 or Google Chrome, go to
• Print forms
hr.jefferson.edu and click on Employee Self-Service.
• Access policies
Sign on with your campus key and password.
Through the website you can access Employee Self-Service
FROM A NON-WORK COMPUTER
(ESS) to:
Go to https://connect.tjuh.org and enter your campus
• View your current benefits
key and password. Click on Employee Self-Service and
• Enroll in benefits
enter your campus key and password again.
• Select and update your beneficiary designations
• View your pay stub
• Review and update your address and phone number
YOUR CAMPUS KEY AND PASSWORD
New employees can call IS&T at 215-955-7975 to obtain
their Campus Key and password.
HR BUSINESS PARTNER
Can’t find an answer to your question on the HR website?
Contact your HR Business Partner about benefits, policies,
employee self-service and general payroll issues. Find out
who your HR Business Partner is by visiting Jefferson.edu/HRBP
while on the network and then clicking the yellow box that
reads, “Who is my HR Business Partner.”
TOTAL COMPENSATION STATEMENT
To see a comprehensive breakdown of the value of your benefits
including compensation, retirement savings, medical and time
off, visit Employee Self-Service at myhr.jefferson.edu using
Internet Explorer 11 or a Google Chrome browser. Click on
Payroll and Compensation and then select My Total Rewards.
To see the value of your benefits, click on the Health and
Wellness tab beneath the pie chart.
2 HUMAN RESOURCES NEW HIRES: Make sure to enroll within 30 days of your hire date.
Eligibility
All regular full-time employees scheduled to work at least 35 hours per week and
regular part-time Jefferson employees scheduled to work 20 or more hours per week
but less than 35 in job classifications designated as benefit eligible can participate
in the Jefferson Benefits Program. Waiting periods are noted below.
Full-Time
Full-Time Faculty, Full-Time
Benefits House Staff
Senior Administrators,
Waiting Other Benefit Eligible Employees
and Full-Time
Periods Postdoctoral
(20–40 hours per week)
Fellows
• Medical
• Vision
• Dental
• Life and AD&D 1st of month on or after date
• Short & Long of hire or date you move to 1st day at work
Term Disability an eligible status
(full-time only)
• Flexible Spending
Accounts
When your benefits begin depends on when you enroll.
If you enroll between the 1st and 15th of the month,
Voluntary
your benefits begin on the first of the following month. If
Benefits Program
you enroll between the 16th and 31st of the month, your
benefits begin on the first of the next following month.
PART-TIME EMPLOYEE BENEFITS PROGRAM
The benefits program includes subsidized benefits for eligible part-time employees
who elect to participate. You are eligible if you are a regular part-time employee in a
benefit-eligible job classification scheduled to work 20 hours or more per week but
less than 35.
Eligible part-time employees may select options for Medical, Dental, Vision coverage,
Life and Accidental Death and Dismemberment Insurance, Spousal and Child(ren)
Life Insurance and the Flexible Spending Accounts. The medical and dental per pay
contributions are higher for part-time employees. Part-time employees are not eligible
to participate in Jefferson’s Disability Programs beyond Earned Time Off accruals.
READY TO ENROLL? Go to page 40 for instructions. ELIGIBILITY 3
Eligible Dependents This information should be sent to:
HRquestions@jefferson.edu or Fax: (215) 503-7455
You may enroll your eligible dependents in a Jefferson medical,
dental, vision, life insurance or AD&D plan. Eligible dependents If you do not provide the required documentation within
include your spouse and children up to age 26. 30 days of enrollment, that dependent will no longer be
entitled to benefits and will be removed from coverage.
The Affordable Care Act regulations require us to report the
social security number for all dependents covered under the Who is not eligible for coverage?
medical plan. You will not be able to proceed with your online • A former spouse
benefit enrollment unless you enter your dependent’s SSN. • A parent or grandchild who resides with you
• A legally domiciled adult and/or domestic partner,
PROOF OF DEPENDENT STATUS
• Any other person who does not meet the eligibility
If you choose to enroll your dependents in benefits, you will requirements
need to submit dependent verification documentation within
30 days from the date you add them as a dependent. See acceptable documentation below.
• Presently valid legal marriage certificate or license (must include date of marriage).
Legally Married Spouse • First page of your prior year Federal income tax return form 1040 that indicates
(any one of these documents) “married filing jointly“ or “married filing separately“ (your spouses name must
appear on the tax form on the line provided after the “married filing separately“
status). Financial information may be blocked out.
• Legal or hospital birth certificate showing the parent/child relationship
with the employee.
• First page of prior year Federal income tax return form 1040 showing the child
listed as a dependent (financial information may be blocked out).
• Baptism certificate showing the parent/child relationship with the employee.
Natural Child, Adopted Child or
Child for whom you are the legal • Official court order (divorce decree/custody agreement) showing
guardian under age 26* the parent/child relationship with the employee.
(any one of these documents)
• Legal adoption papers showing the parent/child relationship with the employee.
• Legal guardianship papers issued by the courts showing
the guardian/child relationship.
In addition, for a disabled child age 26 or older, an Application to Continue Coverage
*
for a Handicapped Dependent Child must be submitted to Independence Blue Cross.
• Legal birth certificate showing parent/child relationship to the spouse of
employee and valid legal marriage certificate between the employee and spouse.
• First page of prior year Federal income tax return form 1040 showing
the child listed as a dependent (financial information may be blocked out).**
• Court order (divorce decree/custody agreement) showing joint
Stepchild under age 26 * or shared legal custody by your spouse.**
(any one of these documents)
• A Qualified Medical Child Support Order (QMCSO) that identifies the child
as requiring benefit coverage through the employee’s spouse.**
In addition, for a disabled child age 26 or older, an Application to Continue Coverage
*
for a Handicapped Dependent Child must be submitted to Independence Blue Cross.
**
If you are an employee providing documentation for a child of your spouse, documentation
must also include any one of the documents listed for spouse even if your spouse is not covered
by the Jefferson benefit plans.
4 ELIGIBLE DEPENDENTS NEW HIRES: Make sure to enroll within 30 days of your hire date.
How And When To
Enroll For Coverage Verify Your
New hires must enroll in benefits within 30 days from date of hire. Employees that have Elections
a status change must enroll in benefits within 30 days of becoming eligible for benefits.
You will be able to verify your
You will need to enroll in benefits online using Employee Self-Service (ESS). The benefits
elections one business day after
you choose will remain in effect until December 31 of that year.
submitting an event by logging
If you do not want Jefferson medical coverage, you must go online and waive into Employee Self Service.
coverage. Otherwise, you will be enrolled in the Gold PPO Plan at employee • Click on Benefits
only coverage. • Click on Benefits Summary
• Fill in applicable date,
OPEN ENROLLMENT
i.e. for future coverage,
Every fall you will have an opportunity to make changes to your benefits during you must enter future date
Open Enrollment. Any changes you make at Open Enrollment take effect on the • Click Go
upcoming January 1.
CHANGING YOUR BENEFITS DURING THE YEAR DUE TO A LIFE EVENT
You can only change your benefit elections during the year if you have a life event,
as defined by the IRS. That is why it is important to review your choices carefully to
ensure the benefits you choose will meet the needs of you and your family throughout
the year. If you have a life event, you can only make a change to your coverage that is
consistent with the life event. For example, if you get married, you may add your spouse
to medical coverage, but may not switch medical plans. Any change you make must be
made within 30 days of the event.
Life Events include:
• Marital status change (marriage, divorce, death of spouse)
• Change in number of dependents (birth, adoption, death of dependent)
• You or one of your covered dependents gain or lose other benefits coverage
• Any other event recognized under applicable law and regulations as a reason
to change an election under the Benefits Program
Marriage, birth or adoption life events can be submitted through Employee Self-Service.
Any required documentation must be submitted to HR Operations within 30 days of the
event. Contact HR Operations at 215-503-4772, press Option 8, and then Option 1 to
report other life event changes.
READY TO ENROLL? Go to page 40 for instructions. ENROLLMENT 5
When Coverage Ends
FOR YOU
Jefferson benefit coverage ends for you upon the following events:
• Medical, vision and dental benefits end on the last day of the
month in which your employment ends or you no longer
meet the applicable eligibility requirements of the plans
• Life
insurance, disability and FSA benefits end on the date
your employment ends or you no longer meet the applicable
eligibility requirements of the plans
FOR YOUR DEPENDENTS
Jefferson benefit coverage ends for your dependents on the date:
• Your coverage ends
• Your dependent no longer meets the definition of an
eligible dependent
• You remove a dependent from coverage due to a life event
Coverage may also end if you stop making required payments,
you misrepresent your dependent’s eligibility status or the plan ends.
COBRA
COBRA requires continuation coverage to be offered to covered employees, their spouses, their former spouses and their dependent
children when group health coverage would otherwise be lost due to certain specific qualifying events. The chart below shows the
specific qualifying events, the qualified beneficiaries and maximum coverage period.
Qualified Maximum Period of
Qualifying Event Beneficiaries Continuation Coverage
Termination (for reasons other than gross misconduct) Employee, Spouse,
18 months
or reduction in hours of employment Dependent Child
Employee enrollment in Medicare Spouse, Dependent Child 36 months
Divorce or legal separation Spouse, Dependent Child 36 months
Death of employee Spouse, Dependent Child 36 months
Loss of “dependent child” status under the plan Dependent Child 36 months
Once the qualifying event has been reported to HR Operations, the qualified beneficiary will receive a COBRA notice in the mail to the
home address on record by our third party administrator, Discovery Benefits. For more information on COBRA, visit the DOL website,
“An Employees’ Guide to Health Benefits under COBRA” at www.dol.gov/ebsa/pdf/cobraemployee.pdf, contact Discovery Benefits at
866-451-3399 or your HR Business Partner.
Platinum Gold
Monthly Cost Platinum PPO Gold PPO Davis Vision
Dental Dental
Beneficiary Only $551.82 $524.28 $6.32 $31.89 $27.75
Beneficiary + Spouse $1,241.34 $1,179.12 $10.85 $63.77 $55.52
Beneficiary + Child(ren) $1,048.56 $995.52 $10.85 ($15.67) $71.74 $62.45
Beneficiary + Family $1,765.62 $1,676.88 $15.67 $95.65 $83.27
6 COVERAGE NEW HIRES: Make sure to enroll within 30 days of your hire date.
Livewell@Jeff PROGRAM REQUIREMENTS
REDBRICK HEALTH Step 1: Tell Us More About Yourself
The LiveWell@Jeff program was established to enhance the quality of life of Complete your online health assessment
Jefferson employees by promoting healthy lifestyles and reducing the risk of by September 1, 2018. It’s a short
illness by using Jefferson’s wide range of educational and clinical resources. questionnaire about your health that
Jefferson has partnered with RedBrick Health to create a rewards program with only takes a few minutes to complete.
an interactive online employee portal. You’ll see your strengths and identify
areas where you can improve.
ELIGIBILITY
Step 2: Know Your Numbers
All benefits-eligible employees of Jefferson, and members of 1199C enrolled
Get a health screening to get a better
in a Jefferson-sponsored medical plan, are eligible to participate in the
picture of your health and submit your
LiveWell@Jeff program.
records to RedBrick Health by September
2018 WELLNESS CREDITS 1, 2018. These will remain confidential
and Jefferson will not have access to any
For employees and spouses who completed LiveWell@Jeff wellness program individual’s health records. It may take up
requirements by September 1, 2017, you will receive a wellness credit of $15 to two weeks for your screening results
per pay. Your covered spouse can earn an additional $10 per pay, regardless to appear on your wellness portal.
of which medical plan you enroll in beginning January 2018.
Step 3: Real-Time Rewards (optional)
NEW PROGRAM YEAR: OCTOBER 1, 2017 – SEPTEMBER 1, 2018
Earn wellness dollars throughout the
We are excited to introduce a new way to earn financial rewards beginning year when participating in healthy
October 1, 2017. Real-Time Rewards allows employees to earn wellness points for activities. Once you complete your
completing healthy activities throughout the year. Once you complete your health online health assessment and biometric
assessment and biometric screening, you can instantly redeem your points for up to health screening, you can instantly
$60 in gift cards (1 point = $1). Additionally, employees who complete the online health redeem up to $60 in gift cards.
assessment and biometric health screening by September 1, 2018 will be eligible for
wellness credits in 2019.
How the Portal Works
Benefits-eligible employees, and members of 1199C enrolled in a Jefferson-
sponsored medical plan, can create an account at MyRedBrick.com/Jefferson.
The RedBrick wellness portal is where you will complete the Health Assessment,
record your healthy activities, and access health information and tools.
Redbrick
Health
Mobile App
Take RedBrick Health with
you on the go! The RedBrick
App gives you a fast and easy
way to track your daily activities,
make progress on your health
improvement journey, and
earn all the rewards of better
health. The activation code is:
“jefferson”
READY TO ENROLL? Go to page 40 for instructions. LIVEWELL@JEFF 7
Information on Health Screenings
There are four ways to complete your Health Screening:
Complete your Health Screening using your own provider. Have your provider complete
Your Own Provider
the Health Screening Form (available on your wellness portal) and submit to RedBrick.
You can schedule your health screening at any time throughout the year at the Jefferson
Onsite at Jefferson Labs
Outpatient Lab by calling 1-800-JEFF-NOW. The lab will submit your results directly to RedBrick.
Complete your health screening at a participating LabCorp. Print a prepaid voucher and search
LabCorp
for a participating LabCorp lab on your wellness portal.
Onsite Screenings Onsite health screenings at Jefferson will be available every spring.
Information on
Real-Time Rewards
In addition to earning wellness credits for 2019, employees
can qualify for gift cards by participating in healthy activities.
Earn wellness points for each activity and instantly redeem
up to $60 in gift cards once you complete your two
program requirements.
Some activities are self-reported, while others will be
awarded by RedBrick upon completion of a program.
Visit www.jefferson.edu/livewell for more information.
Examples of Healthy Activites (1 point = $1)
Annual Physical = 10 points EXOS Program = 15 points RedBrick Track = 1 point/day
Behavior Modification
Dental Exam = 10 points Lunch & Learn = 5 points
Program = 15 points
Vision Exam = 10 points Nutrition Program = 15 points Financial Wellness = 5 points
Preventative Screenings = 10 points RedBrick Journey = 15 points Health/Wellness Fair = 5 points
RedBrick Challenge = 10 points Community Walks/Runs = 15 points Volunteer/Donate Blood = 5 points
8 LIVEWELL@JEFF NEW HIRES: Make sure to enroll within 30 days of your hire date.Medical Plans
MEDICAL PLANS AT A GLANCE
Jefferson gives you a choice of two medical plans
administered through Independence Blue Cross:
• Platinum PPO • Gold PPO
In 2018, you have a choice of four coverage categories.
This is a change from our previous structure.
• Employee only • Employee + Spouse
• Employee + Child(ren) • Family
Terms to Know Here are some important terms to help you understand how the plans pay benefits.
Our benefit plans pay expenses based on the allowable amount. This is the average charge, or “going
rate” for a specific service in a geographic area. Network providers have agreed to accept the allowable
Allowable
amount, while out-of-network providers may charge above the allowable amount. With an Out
Amount
of Network provider, you may be responsible for the amount over the allowable amount, in addition
to any deductibles, coinsurance or copays your plan requires.
The percentage of an eligible expense the plan pays (such as 70%).
Coinsurance
You pay the remaining percentage (such as 30%) and this counts toward the out-of-pocket maximum.
The flat dollar amount you pay for some services (such as $20) at the time care is received.
Copay
Copays count toward the out-of-pocket maximum.
The amount of eligible expenses you pay before the plan pays benefits.
Deductible
The deductible counts toward the out-of-pocket maximum.
This is the maximum amount you or your family must pay in coinsurance, copays and deductibles
Out of Pocket
toward eligible expenses in a calendar year. Generally, when you reach the out-of-pocket maximum
Maximum
the plan will pay 100% for most eligible expenses.
Pre-existing
The medical plans do not restrict benefits based on pre-existing conditions.
Limitations
READY TO ENROLL? Go to page 40 for instructions. MEDICAL PLANS 9Cost of Coverage
The bi-weekly cost varies based on the: If you’re enrolled in the medical plan and attest to being a smoker,
• Medical option you choose you will be charged a $25 per pay premium. If your spouse smokes,
• Number of dependents you choose to cover a $25 per pay smoker premium will apply for spouses enrolled in the
• Smoker status for you and your spouse medical plan. During the online enrollment process, you will answer
• Wellness program participation for you and your spouse questions regarding you and your spouse’s smoker status. The premiums
• Whether or not your covered spouse is eligible will apply if you indicate you or your spouse smokes or if you do not
for medical coverage through another employer answer the question, and enroll your spouse in the medical plan.
Research shows that there is a growing
trend for employer plans to charge
MEDICAL CONTRIBUTION RATES—PER PAY PERIOD
more to cover spouses who have access
to health insurance through another
Full-Time Employees PLATINUM PPO GOLD PPO employer. In reviewing our plans,
we’ve found that Jefferson covers more
Employee Only $48 $39 spouses — taking on a larger medical
responsibility than other employers.
Employee + Spouse $109 $90 If your spouse has medical coverage
available through another employer
and you choose to cover your spouse
Employee + Child(ren) $99 $75
under a Jefferson medical plan, you will
pay an additional $40 per pay for the
Family $170 $140
coverage. During the online enrollment
process, you’ll be asked if your spouse
Part-Time Employees PLATINUM PPO GOLD PPO
has coverage available through another
employer. The charge will only apply if
Employee Only $115 $100 your spouse has other available coverage
or if you do not answer the question,
Employee + Spouse $241 $214 and enroll your spouse in medical.
Employee + Child(ren) $220 $200 Your cost for the medical plan is
deducted from your pay on a pre-tax
Family $362 $314 basis. The rates shown here are prior
to any credits or premiums.
10 COST OF COVERAGE NEW HIRES: Make sure to enroll within 30 days of your hire date.Platinum and Gold PPO Plans
HOW THE PLATINUM AND GOLD PLANS WORK
The Platinum and Gold PPO medical plans allow complete freedom of choice of
providers. Research shows that a patient with a relationship with a PCP has better
coordinated care, better outcomes, with less cost and waste. For both the Platinum
and the Gold Plans, Primary Care Office copays under Tier 1 (Home) are free.
Referrals are not required with the medical plans.
The Platinum PPO plan provides a high level of comprehensive coverage, with 100%
coverage for services through Home facilities. You will pay more per pay period for
the Platinum PPO plan.
The Gold PPO plan is a lower-level coverage option that still provides important
protections and costs less per pay period. You will pay a modest deductible for Home
facility services and pay overall higher out-of-pocket costs when you go to the doctor.
It is important to note that infertility and hearing aid services are not covered by the
Gold PPO plan.
You decide which network to choose a provider from when seeking medical care.
• Tier 1 Home ($): You receive care from a home JeffCare network provider
• Tier 2 Non-Home ($$): You receive care from a non-home JeffCare network provider
• Tier 3 ($$$): You receive care from a Personal Choice provider
• Tier 4 ($$$$): You receive care from an out-of-network provider
If you receive care at a JeffCare network facility or a JeffCare network provider,
you receive the highest level of benefits. This higher level of benefit is only available
if the service is available through a JeffCare network provider.
HOSPITAL NETWORK
The JeffCare Tier 1 (Home) Tier 2 (Non-Home)
Hospital Network • TJUH, JHN, Methodist • Nemours
The network of providers is identical in both plans. • Abington, Lansdale • Wills Eye (Center City only)
Visit www.jeffnetworks.org and click on 2018 for • Aria • Doylestown
the most up-to-date listing of facilities and providers • Kennedy • Magee
in Tiers 1 and 2. Go to www.ibx.com to search for • Bala Endoscopy Center
providers in the Personal Choice network. • Rothman Orthopedic
Specialty Hospital
• Main Line Health Hospitals
READY TO ENROLL? Go to page 40 for instructions. MEDICAL PLANS 11Livongo for Diabetes
Employees and dependents enrolled in a Jefferson medical plan,
and are diagnosed with type 1 or type 2 diabetes can enroll in
the Livongo for Diabetes program at no cost.
Benefits
• Unlimited Test Strips at no cost shipped to your home
with no copays
• The Livongo connected meter provides real time tips
and uploads readings
• Livongo coaches are Certified Diabetes Educators who
can assist you with nutrition and lifestyle changes.
To join or learn more: welcome.livongo.com/JEFF
or call Livongo Member Support at (800) 945-4355
What is Not Covered?
*
At this time the Livongo meter does not integrate with insulin pumps. • Services not medically necessary
If you use an insulin pump, please discuss the use of Livongo with your • Services or supplies which are experimental or investigative
healthcare team. except routine costs associated with clinical trials
• Reversal of voluntary sterilization
JeffConnect • Expenses related to organ donation for non-member
recipients
Fast easy way to see a Jefferson Doctor! Go to jeffconnect.org • Alternative therapies/complementary medicine
to enroll. Initiate a video visit on your computer or mobile device. • Dental care, including dental implants, and non-surgical
Available 24/7/365. treatment of temporomandibular joint syndrome (TMJ)
• Music therapy, equestrian therapy, and hippotherapy
• Treatment of sexual dysfunction not related to organic disease
except for sexual dysfunction resulting from injury
• Routine foot care, unless medically necessary or associated
with the treatment of diabetes
• Foot orthotics, except for orthotics and podiatric appliances
required for the prevention of complication associated with
diabetes
• Routine physical exams for non-preventative purposes such
as insurance of employment applications, college, or
premarital examinations
• Immunizations for travel or employment
• Service or supplies payable under Workers’ Compensation,
Motor Vehicle Insurance, or other legislation of similar purpose
• Cosmetic services/supplies
• Self-injectable drugs
• Infertility Treatment under the Gold PPO Plan
• Hearing aid services under the Gold PPO Plan
12 MEDICAL PLANS NEW HIRES: Make sure to enroll within 30 days of your hire date.Platinum PPO Plan | 2018 Plan Summary
Benefits JeffCare Home JeffCare Non-Home Personal Choice Network Out-of-Network*
Deductible (Individual) None $100 $1,000 $1,500
Deductible (Family) None $300 $3,000 $4,500
Benefit Period Calendar Year Calendar Year Calendar Year Calendar Year
Coinsurance
100% unless 100% unless 70% after deductible unless 60% after deductible
(percentage paid by plan except
otherwise noted otherwise noted otherwise noted unless otherwise noted
hearing aid benefit)
Out-of-Pocket Maximum***
$2,000 $2,5004 $3,5004 $5,000
(Individual)
Out-of-Pocket Maximum***
$4,000 $5,0004 $7,0004 $10,000
(Family)
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited
Doctor’s Office Visits
$0 Copayment $15 Copayment $30 Copayment 60% after deductible
(Primary Care Services)
Doctor’s Office Visits
$30 Copayment $45 Copayment $60 Copayment 60% after deductible
(Specialist Services)
Preventative Care
100% 100% 100% 60% after deductible
for Adults & Children
Pediatric Immunizations 100% 100% 100% 60% after deductible
Routine Gynecological
Exam/Pap (1 routine exam/pap
100% 100% 100% 60% after deductible
test per calendar year
for women of any age1)
Mammogram 100% 100% 100% 60%
Nutrition Counseling
for Weight Management 100% 100% 100% 100% after deductible
(6 visits per calendar year1)
Outpatient Diagnostic
$15 Copayment $20 Copayment 70% 60% after deductible
Services (Routine Radiology)
Outpatient Diagnostic
Services (Advanced Radiology – $40 Copayment $60 Copayment 70% after deductible 60% after deductible
MRI/MRA/CAT/PET)
Outpatient Diagnostic $25 Copayment
100% $10 Copayment 60% after deductible
Services (Laboratory) per occurrence
Allergy Testing 100% 100% 70% after deductible 60% after deductible
Allergy Extract / Injections 100% 100% 70% after deductible 60% after deductible
Maternity (First OB Visit) $30 Copayment $45 Copayment $60 Copayment 60% after deductible
$350 Copayment
Maternity (Hospital)6 100% 70% after deductible3 60% after deductible2
per admission3
Contraceptives 100% 100% 100% 60% after deductible
Infertility Diagnosis
100% after 70% after deductible 70% after deductible
and Treatment 60% after deductible
applicable copayment and applicable copayment and applicable copayment
($20,000 per lifetime1)
Elective Abortion6 100% $250 Copayment 70% after deductible 60% after deductible
Inpatient Hospital Services **
$350 Copayment
• Facility 100% 70% after deductible3 60% after deductible2
per admission3
• Professional/Physician6 100% 100% 70% after deductible 60% after deductible
Inpatient Hospital Days 1
365 365 365 702
$150 Copayment $150 Copayment $150 Copayment $150 Copayment
Emergency Care (copayment waived (copayment waived (copayment waived (copayment waived
if admitted) if admitted) if admitted) if admitted)
Urgent Care Center $45 Copayment $55 Copayment $70 Copayment 60% after deductible
Retail Clinic $20 Copayment $25 Copayment $30 Copayment 60% after deductible
Telemedicine 5
$5 Copayment Not Covered Not Covered Not Covered
Outpatient Surgery (Voluntary sterilization procedures included; Reversal of sterilization procedures excluded)
$250 Copayment
• Facility 100% 70% after deductible 60% after deductible
per occurrence
• Professional/Physician 6 100% 100% 70% after deductible 60% after deductible
Ambulance (Emergency) 100% 100% 100% 100%
Ambulance (Non-Emergency) 80% 80% 80% 50% after deductible
READY TO ENROLL? Go to page 40 for instructions. MEDICAL PLANS 13Platinum PPO Plan | 2018 Plan Summary, Continued
Benefits JeffCare Home JeffCare Non-Home Personal Choice Network Out-of-Network*
Therapy Services (Physical,
Speech and Occupational; $15 Copayment $20 Copayment $40 Copayment 60% after deductible
60 visits per calendar year1)
• Cardiac Rehabilitation
$15 Copayment $20 Copayment $40 Copayment 60% after deductible
(36 visits per calendar year1)
• Pulmonary Rehabilitation
$15 Copayment $20 Copayment $40 Copayment 60% after deductible
(12 visits per calendar year1)
• Respiratory Therapy $15 Copayment $20 Copayment $40 Copayment 60% after deductible
• Orthoptic/Pleoptic
$15 Copayment $20 Copayment $40 Copayment 60% after deductible
(8 sessions lifetime1)
Hearing Aid Exam 100% 100% 100% 60% after deductible
Hearing Aid Reimbursement
25% 25% 25% after deductible 25% after deductible
(2 hearing aids every 36 months1)
Cranial Prosthesis (only covered
for members receiving cancer 50% 50% 50% after deductible 50% after deductible
treatment, one per year1)
Restorative Services,
including Chiropractic Care Not Available $40 Copayment $40 Copayment 60% after deductible
(30 visits per calendar year1)
Chemo / Radiation / Dialysis 100% 100% 70% after deductible 60% after deductible
Outpatient Private Duty Nursing
100% 100% 70% after deductible 60% after deductible
(360 hours per calendar year1)
Skilled Nursing Facility
100% $350 Copayment per admission3 70% after deductible3 60% after deductible
(120 days per calendar year1)
• Professional/Physician 100% 100% 70% 60% after deductible
Home Health Care
100% 100% 70% 60% after deductible
(120 days per calendar year1)
Hospice 100% $350 Copayment per admission3 70% after deductible3 60% after deductible
• Professional/Physician 100% 100% 70% after deductible 60% after deductible
Infusion Therapy 100% 100% 70% after deductible 60% after deductible
Mental Health Care/Serious Mental Illness Care
• Outpatient Services $0 Copayment $15 Copayment $30 Copayment 60% after deductible
• Inpatient Facility Services 100% $350 Copayment per admission3 70% after deductible3 60% after deductible2
• Professional/Physician 100% 100% 70% after deductible 60% after deductible
Substance Abuse Treatment
• Outpatient/Partial Services $0 Copayment $15 Copayment $30 Copayment 60% after deductible
• Inpatient Rehabilitation 100% $350 Copayment per admission3 70% after deductible3 60% after deductible2
• Detoxification 100% $350 Copayment per admission 3
70% after deductible 3
60% after deductible2
Oral Surgery/Dental Care (for the removal of impacted wisdom teeth, which are partially or totally covered by bone; must coordinate through dental plan covered)
$250 Copayment per
100% after deductible 70% after deductible 60% after deductible
occurrence after deductible
• Professional/Physician 100% 100% 70% after deductible 60% after deductible
Durable Medical Equipment Not Available Not Available 70% 60% after deductible
Prosthetics Not Available Not Available 70% 60% after deductible
Outpatient Diabetic Education 100% 100% 100% Not Covered
Transplant Services
100% 100% 70% after deductible 60% after deductible
Professional Services
Medical Foods and
100% 100% 70% 60% after deductible
Nutritional Formulas
Blood 100% 100% 70% after deductible 60% after deductible
Diabetic Equipment & Supplies 100% 100% 100% 60% after deductible
*
Non-Preferred Providers may bill you the differences between the Plan allowance, which is the amount paid by Independence ***
In-network out-of-pocket maximum includes deductible, copays and coinsurance.
Blue Cross (IBC), and the actual charge of the provider. This amount may be significant. Claims for Non-Preferred Professional Out-of-network out-of-pocket maximum includes deductible and coinsurance.
Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charger or the
provider. For covered services that are not recognized or reimbursed by Medicare, payment is based on the lesser of the
1
Combined all networks
Independence Blue Cross (IBC) applicable proprietary fee schedule or the actual charge of the provider. For covered services
2
Inpatient hospital day limit combined for all out-of-network inpatient medical,
not recognized or reimbursed by Medicare or IBC’s fee schedule, payment is 60% of the actual charger of the provider. It is maternity, mental health, serious mental illness and substance abuse services
important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the actual
3
Inpatient Copayment waived if readmitted within 10 days of discharge
charge of the provider.
4
Combined JeffCare Home, JeffCare Non-Home and Personal Choice Network
5
Telemedicine is a carved out benefit through JeffConnect. Copayments do not
NOTE: Impatient copay is waived for admissions to JeffCare Non-Home facilities through the emergency room. For inpatient
**
count toward the out-of-pocket maximum.
hospital admissions through the emergency room at Personal Choice and BlueCard facilities, the claim is to be processed as a 6
Not all anesthesia providers utilized in JeffCare Home or JeffCare Non-Home
JeffCare Non-Home admission (deductible and coinsurance are waived, Non-Home copayment applies.) facilities are JeffCare providers. You may incur a higher member responsibility.
14 MEDICAL PLANS NEW HIRES: Make sure to enroll within 30 days of your hire date.Gold PPO Plan | 2018 Plan Summary
Benefits JeffCare Home JeffCare Non-Home Personal Choice Network Out-of-Network*
Deductible (Individual) $200 $300 $1,500 $3,000
Deductible (Family) $600 $900 $4,500 $9,000
Benefit Period Calendar Year Calendar Year Calendar Year Calendar Year
Coinsurance
100% unless 100% unless 60% after deductible 50% after deductible
(percentage paid by plan except
otherwise noted otherwise noted unless otherwise noted unless otherwise noted
hearing aid benefit)
Out-of-Pocket Maximum***
$3,500 $4,0004 $5,0004 $7,000
(Individual)
Out-of-Pocket Maximum***
$7,000 $8,0004 $10,0004 $14,000
(Family)
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited
Doctor’s Office Visits
$0 Copayment $25 Copayment $40 Copayment 50% after deductible
(Primary Care Services)
Doctor’s Office Visits
$45 Copayment $60 Copayment $75 Copayment 50% after deductible
(Specialist Services)
Preventative Care
100% 100% 100% 50% after deductible
for Adults & Children
Pediatric Immunizations 100% 100% 100% 50% after deductible
Routine Gynecological
Exam/Pap (1 routine exam/pap
100% 100% 100% 50% after deductible
test per calendar year
for women of any age1)
Mammogram 100% 100% 100% 50%
Nutrition Counseling
for Weight Management 100% 100% 100% 100% after deductible
(6 visits per calendar year1)
Outpatient Diagnostic
$25 Copayment $40 Copayment 60% 50% after deductible
Services (Routine Radiology)
Outpatient Diagnostic
Services (Advanced Radiology – $75 Copayment $100 Copayment 60% after deductible 50% after deductible
MRI/MRA/CAT/PET)
Outpatient Diagnostic $40 Copayment
100% $25 Copayment 50% after deductible
Services (Laboratory) per occurrence
Allergy Testing 100% 100% 60% after deductible 50% after deductible
Allergy Extract / Injections 100% 100% 60% after deductible 50% after deductible
Maternity (First OB Visit) $45 Copayment $60 Copayment $75 Copayment 50% after deductible
$500 Copayment per
Maternity (Hospital)6 100% after deductible 60% after deductible3 50% after deductible2
admission after deductible3
Contraceptives 100% 100% 100% 50% after deductible
Infertility Treatment Not Covered Not Covered Not Covered Not Covered
Elective Abortion 6
100% after deductible $350 Copayment after deductible 60% after deductible 50% after deductible
Inpatient Hospital Services **
$500 Copayment per
• Facility 100% after deductible 60% after deductible3 50% after deductible2
admission after deductible3
• Professional/Physician6 100% 100% 60% after deductible 50% after deductible
Inpatient Hospital Days1 365 365 365 702
$160 Copayment $160 Copayment $160 Copayment $160 Copayment
Emergency Care (copayment waived (copayment waived (copayment waived (copayment waived
if admitted) if admitted) if admitted) if admitted)
Urgent Care Center $65 Copayment $75 Copayment $85 Copayment 50% after deductible
Retail Clinic $30 Copayment $35 Copayment $40 Copayment 50% after deductible
Telemedicine5 $15 Copayment Not Covered Not Covered Not Covered
Outpatient Surgery (Voluntary sterilization procedures included; Reversal of sterilization procedures excluded)
$350 Copayment
• Facility 100% after deductible 60% after deductible 50% after deductible
per occurrence after deductible
• Professional/Physician 6 100% 100% 60% after deductible 50% after deductible
Ambulance (Emergency) 100% 100% 100% 100%
Ambulance (Non-Emergency) 70% 70% 70% 50% after deductible
READY TO ENROLL? Go to page 40 for instructions. MEDICAL PLANS 15Gold PPO Plan | 2018 Plan Summary, Continued
Benefits JeffCare Home6 JeffCare Non-Home6 Personal Choice Network Out-of-Network*
Therapy Services (Physical,
Speech and Occupational; $20 Copayment $30 Copayment $45 Copayment 50% after deductible
60 visits per calendar year1)
• Cardiac Rehabilitation
$20 Copayment $30 Copayment $45 Copayment 50% after deductible
(36 visits per calendar year1)
• Pulmonary Rehabilitation
$20 Copayment $30 Copayment $45 Copayment 50% after deductible
(12 visits per calendar year1)
• Respiratory Therapy $20 Copayment $30 Copayment $45 Copayment 50% after deductible
• Orthoptic/Pleoptic
$20 Copayment $30 Copayment $45 Copayment 50% after deductible
(8 sessions lifetime1)
Hearing Aid Exam Not Covered Not Covered Not Covered Not Covered
Hearing Aid Reimbursement
Not Covered Not Covered Not Covered Not Covered
(2 hearing aids every 36 months1)
Cranial Prosthesis (only covered
for members receiving cancer 50% 50% 50% after deductible 50% after deductible
treatment, one per year1)
Restorative Services,
including Chiropractic Care Not Available $50 Copayment $50 Copayment 50% after deductible
(30 visits per calendar year1)
Chemo / Radiation / Dialysis 100% after deductible 100% after deductible 60% after deductible 50% after deductible
Outpatient Private Duty Nursing
100% after deductible 100% after deductible 60% after deductible 50% after deductible
(360 hours per calendar year1)
Skilled Nursing Facility $500 Copayment per admission
100% after deductible 60% after deductible3 50% after deductible
(120 days per calendar year1) after deductible3
• Professional/Physician 100% 100% 60% after deductible 50% after deductible
Home Health Care
100% after deductible 100% after deductible 60% 50% after deductible
(120 days per calendar year1)
$500 Copayment per
Hospice 100% 60% after deductible3 50% after deductible
admission after deductible3
• Professional/Physician 100% 100% 60% after deductible 50% after deductible
Infusion Therapy 100% after deductible 100% after deductible 60% after deductible 50% after deductible
Mental Health Care/Serious Mental Illness Care
• Outpatient Services $0 Copayment $25 Copayment $40 Copayment 50% after deductible
$500 Copayment per
• Inpatient Facility Services 100% after deductible 60% after deductible 3
50% after deductible2
admission after deductible3
• Professional/Physician 100% 100% 60% after deductible 50% after deductible
Substance Abuse Treatment
• Outpatient/Partial Services $0 Copayment $25 Copayment $40 Copayment 50% after deductible
$500 Copayment per
• Inpatient Rehabilitation 100% after deductible 60% after deductible3 50% after deductible2
admission after deductible3
$500 Copayment per
• Detoxification 100% after deductible 60% after deductible3 50% after deductible2
admission after deductible3
Oral Surgery/Dental Care (for the removal of impacted wisdom teeth, which are partially or totally covered by bone; must coordinate through dental plan covered)
$350 Copayment per
100% after deductible 60% after deductible 50% after deductible
occurrence after deductible
• Professional/Physician 100% 100% 60% after deductible 50% after deductible
Durable Medical Equipment Not Available Not Available 60% 50% after deductible
Prosthetics Not Available Not Available 60% 50% after deductible
Outpatient Diabetic Education 100% 100% 100% Not Covered
Transplant Services $500 Copayment per
100% after deductible 60% after deductible 50% after deductible
Professional Services admission after deductible
Medical Foods and
100% 100% 60% 50% after deductible
Nutritional Formulas
Blood 100% 100% 60% after deductible 50% after deductible
Diabetic Equipment & Supplies 100% 100% 100% 50% after deductible
*
Non-Preferred Providers may bill you the differences between the Plan allowance, which is the amount paid by Independence ***
In-network out-of-pocket maximum includes deductible, copays and coinsurance.
Blue Cross (IBC), and the actual charge of the provider. This amount may be significant. Claims for Non-Preferred Professional Out-of-network out-of-pocket maximum includes deductible and coinsurance.
Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charger or the
provider. For covered services that are not recognized or reimbursed by Medicare, payment is based on the lesser of the
1
Combined all networks
Independence Blue Cross (IBC) applicable proprietary fee schedule or the actual charge of the provider. For covered services
2
Inpatient hospital day limit combined for all out-of-network inpatient medical,
not recognized or reimbursed by Medicare or IBC’s fee schedule, payment is 60% of the actual charger of the provider. It is maternity, mental health, serious mental illness and substance abuse services
important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the actual
3
Inpatient Copayment waived if readmitted within 10 days of discharge
charge of the provider.
4
Combined JeffCare Home, JeffCare Non-Home and Personal Choice Network
5
Telemedicine is a carved out benefit through JeffConnect. Copayments do not
NOTE: Impatient copay is waived for admissions to JeffCare Non-Home facilities through the emergency room. For inpatient
**
count toward the out-of-pocket maximum.
hospital admissions through the emergency room at Personal Choice and BlueCard facilities, the claim is to be processed as a 6
Not all anesthesia providers utilized in JeffCare Home or JeffCare Non-Home
JeffCare Non-Home admission (deductible and coinsurance are waived, Non-Home copayment applies.) facilities are JeffCare providers. You may incur a higher member responsibility.
16 MEDICAL PLANS NEW HIRES: Make sure to enroll within 30 days of your hire date.Prescription Plans
There are two prescription plans in 2018. You will automatically You can receive up to a 30 day supply of medication at any of
be enrolled in the Platinum or Gold prescription plan based the domestic pharmacies or at a retail pharmacy. You pay less
on which medical plan you select. MedImpact administers out of pocket when you use a domestic pharmacy. Medications
the plans. Visit their website at: www.medimpact.com. that you take on a regular long-term basis (“maintenance
The prescription drug program offers three ways to obtain medications”) must be filled at a domestic pharmacy or the
your medications – at Abington, Aria, and Jefferson Outpatient MedImpact Direct Home Delivery Pharmacy after the first
Pharmacies (Domestic), at your local retail pharmacy or the refill. You can receive up to a 90-day supply of medication
MedImpact Direct Home Delivery Pharmacy. for one maintenance copay. Domestic pharmacies will mail
prescriptions upon request.
HOW THE PLANS WORK
Specialty drugs are high-cost oral or injectable medications
Jefferson uses the MedImpact Portfolio Formulary.
used to treat complex chronic conditions. It is the fastest
The formulary is a list of preferred medications developed
growing, most costly area of pharmacy care. You can receive
by MedImpact and a group of independent doctors and
up to a 30-day supply of specialty medications for the
pharmacists. They look at how new and existing drugs
copays listed in the last column of the chart below. Specialty
should be covered by the plan. They review drug safety and
medications must be filled at a Domestic Pharmacy from the
effectiveness and recommend quality drugs that provide the
first fill. If a specialty medication cannot be filled at the Jefferson
best value. The formulary is updated several times a year and is
Specialty Pharmacy, they will work with you to transfer it to the
available on the MedImpact website – www.medimpact.com.
MedImpact Direct Specialty Pharmacy.
You will pay less for preferred medications.
Initial Script for • Get a prescription from your doctor for up to a 90-day supply, plus refills for
Maintenance up to one year (if needed)
Medications
(30–90 day fills) • Ask your doctor to fax your prescription to your Home pharmacy or drop off your prescription
Home
• Pick up or have your prescription mailed to you (usually within 24–48 hours)
Pharmacies
GETTING STARTED WITH MEDIMPACT DIRECT HOME DELIVERY IS EASY
Choose one of these ways to fill your first prescription using MedImpact Direct Home Delivery:
• Login to medimpactdirect.com
Online • Select ‘Get Started‘ or ‘Transfer Prescriptions‘
• Select the medication you would like to switch to home delivery
• Get a prescription from your doctor for up to a 90-day supply, plus refills for
up to one year (if needed)
By Mail
• Go to medimpact.com and download an order form
• Mail the new prescription and order form to the address provided on the form
• Get a prescription from your doctor for up to a 90-day supply, plus refills for
up to one year (if needed)
With Your Doctor
• Ask your doctor to electronically submit your prescription to MedImpactDirect
or fax it to 1-888-783-1773.
• Download the MedImpact App from the Apple App Store or Google Play
MedImpact App
• Transfer a retail prescription to home delivery
READY TO ENROLL? Go to page 40 for instructions. PRESCRIPTION PLANS 17TIMING Once MedImpact receives your order, your medication should arrive within 10 business days. Completed refill orders should arrive in about seven business days. To fill a maintenance medication faster, use a Domestic pharmacy. You can also get your 90-day prescription filled at a Domestic Pharmacy. Have your doctor or you send your 90 day prescription to one of our Domestic pharmacies for quick turn around, usually within 24-48 hours. MANAGE YOUR HOME DELIVERY PRESCRIPTIONS ON THE MEDIMPACT WEBSITE OR APP Once you have submitted a home delivery prescription, you can use the MedImpact website or App to: • Refill prescriptions: Refill current MedImpact home delivery prescriptions. All eligible refills will be automatically checked. Deselect any medications you do not want to refill at this time. • Renew prescriptions: Request to renew a home delivery prescription if you are out of refills. • Check order status: Check the status of your home delivery medication orders. MANDATORY GENERIC DRUGS You are required to purchase generic drugs when they are available. If you or your doctor chooses a brand name drug when a generic is available, you will be required to pay the difference in cost between the generic and the brand, along with the applicable brand copay. If you need to file an appeal to the Mandatory Generic program, you, or your covered dependent, must try a full prescription of the generic drug before requesting a brand name replacement. You, your pharmacist or your doctor can start the review process by contacting the prior authorization department at MedImpact. PRESCRIPTION MANAGEMENT PROGRAMS The prescription plan has several management programs to improve care and help manage costs: • Prior Authorization Program: requires authorization for some medications that are only approved or effective in treating specific illnesses, cost more or may be prescribed for conditions for which safety and effectiveness have not been well-established. • Quantity Limit Program: sets limits based on the FDA approved indications, the manufacturer’s package labeling instructions and well-accepted or published clinical recommendations. • Step Therapy Program: encourages you to try first-line medications that deliver similar value, safety and effectiveness, but cost less than others. 18 PRESCRIPTION PLANS NEW HIRES: Make sure to enroll within 30 days of your hire date.
Prescription Benefits at a Glance
PLATINUM GOLD
Prescription
Program Brand Brand Brand Brand
Generic Generic
Formulary Non-Formulary Formulary Non-Formulary
Deductible None None None $100 per individual
Domestic
$40 $60
Non-Maintenance $10 $20 $30 $15
after deductible after deductible
(30 day)
20% 40%
Retail
20% 40% ($40 min–$100 ($60 min–$150
Non-Maintenance $15 $20
($30 min–$50 max) ($50 min–$100 max) max) after max) after
(30 day)
deductible deductible
Maintenance 20% 40%
Jefferson or MedImpact $25 $50 $75 $30 ($100 max) after ($150 max) after
Home Delivery (90 day) deductible deductible
$60 $100
Specialty (30 day) $20 $30 $50 $40
after deductible after deductible
Out-of-Pocket Max $1,500 individual / $3,000 family $2,000 individual / $4,000 family
Save on Prescriptions
REDUCE YOUR OUT-OF-POCKET EXPENSE WHEN YOU USE A DOMESTIC PHARMACY.
Hours Hours
Facility Location Address Phone
M–F SAT
Jefferson Gibbon Building
111 South 11th Street 215-955-8845 7 a.m.–6 p.m. 9 a.m.–4 p.m.
Apothecary Lobby
Jefferson
1st Floor Lobby 833 Chestnut Street 215-955-4400 8:30 a.m.–5:30 p.m. 9 a.m.–1 p.m.
Pharmacy
Jefferson
Walnut Street 908 Walnut Street 215-503-1135 8:30 a.m.–5:30 p.m. 9 a.m.–1 p.m.
Pharmacy
Methodist
2301 South
Hospital Broad Street 215-952-9385 8:30 a.m.–5 p.m. NA
Broad Street
Apothecary
Jefferson
Medications are hand-delivered to your home or
Specialty 215-955-8154 8 a.m.–5 p.m. NA
office, as requested; remote locations are shipped.
Pharmacy
Aria MOB Torresdale
10800 Knights Road 215-612-4949 8:30 a.m.–5 p.m. NA
Pharmacy 1st Floor
Alliance
AJH Main Campus 1245 Highland Avenue 215-481-4318 7:30 a.m.–5:30 p.m. NA
Pharmacy
READY TO ENROLL? Go to page 40 for instructions. PRESCRIPTION PLANS 19GETTING PRESCRIPTION FILLED WHILE AWAY FROM HOME DEDUCTIBLE
MedImpact is affiliated with over 65,000 pharmacies nationwide. You should have no The Platinum Rx plan has no deductible.
problem filling a prescription at a participating pharmacy anywhere in the U.S. Simply The Gold Rx plan has a deductible of
present your I.D. card. MedImpact participating pharmacies are online via computer $100 per person. The deductible only
with MedImpact and will submit your claim electronically at the time the prescription applies to brand (formulary or non-
is filled. You pay only your applicable copayment or coinsurance. formulary) prescriptions. It does not
apply to generic prescriptions.
If you do not use a participating pharmacy, you must pay the full cost of the
prescription, usually at the full retail cost – you will not benefit from the “plan discount.” OUT-OF-POCKET MAXIMUM
You must complete and send a claim form to MedImpact no later than 180 business
The out-of-pocket maximum in the
days from the date the prescription was dispensed. You will then be reimbursed only Platinum Rx plan is $1,500 per person
for the amount that MedImpact would have covered.
or $3,000 per family. The out-of-
pocket maximum in the Gold Rx plan is
CHARGES NOT COVERED
$2,000 per person or $4,000 per family.
Some prescription drugs and supplies are not covered under this plan. Once you reach the out-of-pocket
The plan does not cover: limit, all covered prescriptions will be
• Allergy serum (covered under the medical plan if administered paid by Jefferson at 100%.
in your physician’s office)
• Dietary aids, cosmetic or other health and beauty aids There is a $5,000 lifetime maximum
• Over-the-counter drugs on non-formulary infertility
• Non-legend vitamins medications in the Platinum Rx plan.
• Medical appliances, such as back braces, bandages, cervical collars The Gold Rx plan does not cover any
• Ostomy products (covered under the medical plan) infertility medications.
• Charges for the administration of any drug
Smoking
Cessation
Support is available to
help you and your family
members quit smoking.
Over-the-counter (OTC)
and prescription smoking
cessation products will
be available at no cost.
OTC products will
require a prescription
from your provider.
20 PRESCRIPTION PLANS NEW HIRES: Make sure to enroll within 30 days of your hire date.You can also read
